Saturday, January 23, 2010

You've navigated a lot of tricky territory in your health care career. You've outlasted your old bosses Chris Dodd and Lane Kirkland, and made room for Chip Kahn - somewhere else. You watched states fail to rein in health care costs in the 1980s, as the hospital industry (then as now a real driver of exorbitant health care expenditures) captured the Certificate of Need programs that were supposed to regulate them. You encouraged unions to turn to second opinions and managed care as a consumer-driven effort to control costs. No luck there. After Clinton care fell apart, you and the nation's employers turned to the insurance industry to hold down rates - a buck would be turned, but it would have to be better than the systems they all knew worked perfectly well in Canada and Europe. (They use their national and state budgets to set a limit on costs. Works like a dream: health care is affordable, health outcomes are pretty good, and politics focuses on, well, whatever it is Foreigners talk about.)

The Bush years were lots of fun for the insurance industry. Yes, employers were increasingly strained by premiums, but they had outs - they could pass on costs to employees, or just drop coverage. And since finance capital increasingly controlled U.S. businesses and the media, the last thing they wanted to do was call down government regulation on you. Or on anybody. Then came the global economic meltdown.

Now we have the Obama era reform. All ready to pass, with one major sticking point: the public option. Your members insisted on universal buy-in, in exchange for ending the egregious abuses commited on the patients of America, pre-existing condition exclusions and rescissions. Got that. The public, being no dope, wanted an escape hatch. You said from day one, no way. An ambitious but pragmatic new Administration, having read up on Harry and Louise, was strategically cordial. Both sides knew it would take a mass uprising or a miracle to overcome your opposition. And here's what happened:

The masses didn't rise up. Trying to figure out how not to get foreclosed, while staying employed and keeping their kids safe, they consistently told pollsters they wanted health reform but they wanted a public option, too. They didn't think highly of governmenrt but liked the insurance industry even less. But rising up, no. About 100 of them tried to get arrested at insurance offices around the country. You told Joe and Ben to lift their little fingers to stop the public option, the civilized way, in the Senate, where it's always done discreetly.

Then we had elections in Virginia, New Jersey and Massachusetts. Turns out the masses just threw up their hands in disgust. Suddenly it was maybe no health reform at all. Your stocks went up. But your press statements expressed alarm.

Some say you can't survive long without the government subsidies you were anticipating from the reform proposals, clear evidence that the whole thing is fatally flawed.

I say it's a game of chicken. And you should call it off.

I'd rather you disappeared. That isn't happening this year. Your interest is perpetual life and wealth. That isn't happening this year either.

We can get legislation that keeps the insurance industry on life support. The trade off is that you bow to the inevitable, with plenty of estate planning and golden parachutes and whatever else you've figured out after all these years about opening the next chapter. Tell Fox News, the White House and the Senatte that you've recalculated. You can manage with a national exchange and a public option, after all. Warn the hospitals and the drug industry. They'll understand. (They'll be soaking up lots of the same gravy as AHIP members. And they'll be around a lot longer, in any case.)

It's good negotiating. You walk away with a bundle and your power just tarnished. There's always tomorrow. But like another famous scrappy survivor, you can decide you'll think about that, tomorrow.

Saturday, January 16, 2010

There are at least 3 narratives driving the health reform debates that need to be articulated and challenged.

1. The right-wing anti-social killer pit-bull perspective. Deserves closer scrutiny and analysis, and I’m not close enough to those people or their organizational links to say anything illuminating.

2. The Obama administration and many conservative Dems in Congress have proposed policies rooted in neoliberal economics that undermine the likely success of reform, and support for it. They perpetuate the fallacy that we can control costs by making health care work like a free market, forcing individuals to make choices about our health care by paying more out of our own pockets, and by choosing from a blinding array of health plans and benefits. In fact cost conscious consumers have no power in a market dominated by mega corporations: hospitals, drug and insurance companies.

This viewpoint has driven most of the bad policy decisions the White House has made and has threatened to drive a stake into the heart of the support for reform. Americans may or may not be ready for Medicare for All but we are damn familiar with what the insurance industry is doing to us. Whatever the policy merits of the public option, abandoning it is, was and will be a serious misstep politically. The Administration may not have the power to get rid of the insurance industry entirely. But it is giving away plenty in subsidies and other forms of life support to AHIP members. It is not fighting for the public option and a standardized benefit package and progressive financing in part because the economic gurus at the White House don’t believe in them.

3. Liberals and progressives have worked hard this year. We might have come out swinging in January fighting for a Medicare-for-all, single payer system. We didn’t. Obama’s decision not to go that route was seen as insurmountable, so no one really tried seriously. Recognizing that we would not achieve single payer this year, progressives turned either to improving the bill, or to public education on single payer without any expectation of influencing the national bill. While many of us advocated both for single payer and for a better national bill, it was left largely to HCAN and various offshoots of the Obama campaign, both constrained by direct links to the Democratic Party, to fight for the merits of progressive proposals like the House’s bill. At this point there are three divergent themes that lead the discussion astray:

a. "It's all determined by corporate money." Corporations hold great sway over political life and decisions. And their money works in part through direct contributions to candidates. But voters matter too. Corporate money sways public opinion. We have a better story and so can we.

b. "We'll fix it in the states. The way to get around this problem is to get active on the state level, where we can more easily get rid of the health insurance industry." There are some progressive state campaigns, no question. But not surprisingly, corporations have figured out how to influence state houses too, many of which meet infrequently and briefly.

c. From one blogger: “The best thing that could happen to Obama (and America) is for Congress to FAIL at passing any health legislation. That would give Obama the chance … to say 'OK, we now know that the system is beyond any rational attempt to repair it. We are starting from scratch.'”

Proposing, at this point, that failing entirely to pass a reform bill will clear the decks for a progressive resurgence defies belief. It is quite clear what the result will be.

I believe that defeating the bill now would not open policy space for further progress. It would leave the insurance industry in the same powerful position it is in now. If we fail to pass a bill, the real dedicated and out front enemies of equity and community will be back in the ascendance politically. If we fail, corporate America has open season. We need to continue to build the power and vision of a progressive movement. I see no scenario in which defeating health reform would hasten that agenda.

If we pass it we get – if we fight for it – more standardization and regulation; more guarantees that employers will actually pay in to the system for benefits, the hope of fewer deaths and bankruptcies due to uninsurance.

The House Progressive Caucus has an agenda we should support. Loudly, proudly and actively. We can fight for single payer and fight for fair financing, progressive standards for affordability, and a stronger public sector – through expanded Medicare, a public option or whatever. It is not up to us to bail out a wrong-minded Administration but it is up to us to challenge their ideas and support our allies in Congress for the policies and strategies they actually believe in.

Won’t defeating the bill automatically generate a new progressive movement, with dynamic candidates, platforms and mobilizations? Nice thought. We certainly need all that. I admit it, here’s where my crystal ball gets cloudy. Ralph Nader’s recent novel imagines a bail-out by visionary billionaires like Warren Buffett. I think people like to win, and after they win they’re ready to fight for more. I felt that way on Nov. 4, 2008. It is going to take some serious thinking and working to get back to that place. There is, though, no alternative.

I am a policy analyst. I worked in the past in the Senate. In 2009 I helped craft the ERISA amendment that passed in the House Education and Labor Committee, building on the great work of others in the House and Senate, and with the support of the California Nurses Association.

As Co-Director of the Center for Policy Analysis, I coordinate the EQUAL Health campaign for Equitable, Quality, Universal, Affordable health care. We sponsor a listserve, analyze proposals, and conduct district legislative visits. Our list reaches progressive health reform advocates, women’s organizations, public health groups, as well as Congressional staff and the media.

Topics today:
Why it is important to fight for and win an ERISA waiver.
More broadly, why it is important to fight and win for progressives.

ERISA
The Employee Retirement Income Security Act (ERISA) is a:federal law that pre-empts the rights of states to enact legislation if it is “related to” employee benefits plans, as well as for other reasons.

It was passed in 1974 at a moment like this one, when Congress expected to pass national health reform, and sought to limit state variations. It has been used in the years since then by employers to initiate court challenges to a wide range of reforms that would require them to contribute to the cost of health benefits.

It is unusual among laws involving health care in that there is no administrative remedy built in to ERISA. Only Congress can take action to definitively change ERISA. Because it has not done so, Hawaii sought and won an ERISA waiver for its state law in 1983, in order to be able to continue its employer mandate system. There has been no subsequent amendment on this subject.

Why progressives must fight for an ERISA waiver

We know how progressives are feeling this week.

We have been encouraged by the statements of Quad Caucus leaders, that we wanted single payer, and the public option is our line in the sand.

At the same time we watched the Senate turn down an abortion amendment, and then be forced to include it.

After winning a victory in committee on an ERISA waiver for single payer states, we saw it fall from HR 3692.

We’ve watched Joe Lieberman move from supporting expanding Medicare, on the air, as recently as September, to hijacking the public option.

We know that your offices did your best to respond to requests for a floor vote on a single payer bill.

We hear that maybe we can get a public option next year, by a majority vote. And maybe we can.

But we also know that the health reform debate is developing as a contest for power.

Progressives cannot emerge from this debate demoralized.

Victory breeds victory. Leadership summons participation.

Progressive leaders have a real opportunity to stand fast for significant policies that we know will make a real difference in people’s lives.

There are a number of important issues on the table, that will vastly improve the health reform bills. These include:
• the public option,
• a strong employer mandate, and affordability protections including adequate subsidies,
• a nationally based health exchange,
• fair financing
• and a strong stand on reproductive rights and immigrants’ rights.

I hope you’ll get a chance to look at our op ed on some of these important issues.

But we know that at best all of these provisions are a step towards a system that is truly universal, controls costs, and improves quality. The fight for single payer systems will move immediately to the states, where there are already strong and successful movements in California, Pennsylvania, Maryland, Illinois, New Mexico, Ariona, and elsewhere.

These campaigns face the same obstacles as the national effort: massive industry spending and opposition, corporate media, the need for organizational bases.

They face one additional obstacle: ERISA.

Single payer advocates around the country are energized around amending this arcane piece of legislation, for two reasons.

First it will make a real, immediate, significant difference in their ability to enact and implement single payer bills. Without an ERISA waiver, single payer states face at a minimum automatic court challenges that could drag on for years.

Equally importantly, it will demonstrate that progressives can and will fight hard, and win, for changes that are fundamental.

This battle has implications far beyond health reform – in itself important enough.

We know we are entering the new decade with a sputtering economy, and a controversial war. We will need a mobilized, energized leadership, and a mobilized, energized base, to take these issues on and win them.

We know the opposition. They are relentless in the minority. They have demonstrated what they will do when in the majority. They cannot be defeated by lukewarm campaigns.

Progressives must have a health reform bill and it must be one we will celebrate at the end of the day. Your offices can demonstrate the leadership and the determination to fight for and win a provision that will be celebrated daily by advocates around the country as our fight for universal coverage continues. Please fight for the ERISA waiver.

[Post-script: An ERISA amendment would be an important victory. The EQUAL campaign continues to advocate for the full range of policies identified in this presentation.]

Tuesday, January 5, 2010

This article appeared on page A - 8 of the San Francisco Chronicle, January 6, 2010.

The insurance industry hates it because it would ding its profits. Democratic leaders fear it could kill passage of health care reform. But reports of the death of the public option have been greatly exaggerated.

Poll after poll shows that Americans want to be able to choose a public insurance plan, and for good reason. It would be tragic to lose this pillar of health care reform to cynical inside-the-Beltway political horse trading. Here's why we need the public option:

It can really deliver on the benefits. The proposed bills would outlaw common and perverse industry loopholes such as pre-existing condition exclusions, which exclude sick people from buying insurance as individuals, and rescissions, which let companies deny treatment retroactively for people they already insure. While outlawing these rules will help, private insurance plans have demonstrated that they are willing to challenge patients' rights to the grave and beyond in the interest of clinging to the premium dollar.

We've witnessed a heartbreaking parade of insured patients trooping to corporate headquarters to plead for lifesaving treatments that were denied, even though the benefits are covered in writing. In contrast, no one at the government-run Medicare program gets a bonus for turning away sick people. We need to be able to choose a plan in which the financial incentives to provide needed care line up with the proposed new laws, and that can only happen in the public sector.

It will drive down costs. Health care reform will cover millions more Americans - a great achievement. But we need to use the increased buying power of this newly covered population to control costs, a job at which private insurance companies consistently fail. Some companies can't reduce premiums because they're too small to hold leverage in negotiations with private hospital chains and big drug companies. Or if they do save a buck, they put it back in their own pockets in the form of profits and executive bonuses.

In Massachusetts, large nonprofit insurers recently testified that they had negotiated sweetheart deals that benefited certain employers and hospitals - and confidentiality agreements that kept the details secret. When the Veterans Administration negotiates lower drug prices, the savings buy more drugs for veterans, and the transactions are all transparent. We'd like to be sure that the change we voted for turns into change we save on reduced premiums, which is possible only in a public plan.

It will allow us to re-engineer how we deliver and pay for care. How? By coordinating with Medicare initiatives that will bolster quality while lowering costs, like financial incentives that promote primary care and better coordination of medications. The public plan will be most effective if it starts right away and is available to everyone - policies we can continue to fight for. But the projection that the public option would offer savings too small for too few, or would be too expensive, is off the mark.

It's democratic. Most Americans know this in our bones. The majority of the House voted for it, including many in our powerhouse delegation from California. The majority of senators expressed support for it - including committee chairs Max Baucus and Tom Harkin. We're tired of arcane rules that let minorities of one hijack the public's interest.

There will be efforts to leverage the public option for other benefits. One benefit of that debate would be if the antitrust exemption for health insurance companies were revoked so they can be regulated by the Federal Trade Commission. But we need a real institutional alternative to the present system. Americans want - and need - a public option. Don't let your representatives trade it away.